Benign Coercion

© Colour | stockfresh.com

© Colour | stockfresh.com

Recently, two psychiatrists, Sally Satel and E. Fuller Torrey, wrote their second article, “Stop ignoring the needs of the seriously mentally ill,” for the American Enterprise Institute in support of the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646).  In their November 3, 2015 article, they bemoaned the opposition of what they referred to as a small but vocal faction of “advocacy groups opposed to all involuntary mental-health care” who have the ear of some committee Democrats.  According to Satel and Torrey, the problem is that these critics and the lawmakers receptive to their claims don’t seem to grasp the difference between serious mental illnesses and less disabling psychiatric conditions.

They highlighted three areas that in their opinion are particularly important aspects of H.R. 2646 that need to be passed. They want to see the creation of a new position, an assistant secretary for mental health and substance abuse, who would: “focus on coordinating the federal government’s programs and elevating the importance of caring for the most debilitated patients.” All the current funding and authority of the existing federal agency, SAMHSA, (Substance Abuse and Mental Health Services Administration) would be placed under this new assistant secretary. Allegedly, these radical advocacy groups oppose the creation of the position because of a threat to their current funding from SAMHSA.

The second major area of concern is the so-called assisted outpatient treatment (AOT) provision. AOT is said to be “a cost-saving and effective form of civil-court-ordered community treatment,” that targets individuals who habitually fall into a pattern of “self-neglect, self-harm, or dangerousness” when they are not taking medication. A judge could order these individuals into mandated and monitored “treatment” while they continue to live in the community. A violation of the court-ordered treatment conditions could results in “an evaluation of a patient’s need for further treatment.”

The third perceived concern is the expansion of psychiatric beds. The main culprit they point to seems to be the “outdated” law called the IMD exclusion, which prohibits Medicaid from paying for care delivered by “institutions for the treatment of mental diseases” (IMDs) for individuals between the ages of 22 and 64. This is supposed to have contributed to a shortage of psychiatric hospital beds. The authors claim there is a need for twice number of existing inpatient beds. Citing data from H-CUP, they said schizophrenia and bipolar illness represented two of the top three causes of 30-day Medicaid inpatient re-admissions. “Along with diabetes, these conditions resulted in about $839 million in hospital costs.”

In truth, these provisions are vital to the reversing the marginalization of the sickest patients by SAMHSA and the inadvertent problems caused by Medicaid’s disincentives. Misconceptions about the needs of these patients must not be allowed to interfere with the bill’s mark-up, so it will emerge from the Health Subcommittee with its bold and much-needed provisions intact.

David Shern, a Senior Associate in the Department of Mental Health at the Bloomberg School of Public Health, John Hopkins University, responded to the article by Satel and Torrey in “We Need REAL Change in Mental Health Policy, Not the Illusion of Reform.” Shern described the above three changes as simplistic approaches that ignore core parts of the problem. “They are ‘quick fix’ solutions that have little promise of doing much to address our contemporary crisis.” He agreed with the key features of the problem: incarcerating too many people with severe mental illness and a lack of effective engagement strategies with the mentally ill population. He agreed that a comprehensive approach to the problems was necessary. But “Drs. Satel and Torrey propose more of the same – strategies that have characterized the last 50 years.”

He said there was no reason to believe that adding an Assistant Secretary title to the existing bureaucracy would make any difference within HHS. Additionally, the new position would have no effect on other governmental departments critical for the community life of mentally ill individuals. “We’ve repeatedly learned that reorganizations are appealing but rarely accomplish the magic that the reorganizers hope to achieve.”

He then observed how “Involuntary Outpatient Commitment” has been renamed as “Assisted Outpatient Treatment” in H.R. 2646. The current legislation does nothing to improve the existing community service capacity. Provisions in the original version of the Helping Families in Mental Health Crisis Act actually called for cut backs in funding for existing community services. I’m not sure if those same cuts are still there. So according to Shern, “Creating a legal mechanism to compel individuals into a non-existent system is a cruel fiction that creates the illusion of fixing a problem.”

Ostensibly, for people who are not compliant with the system’s idea of care, having a judge order an individual to comply with the treatment plan will fix the problems of an inadequate system. (An inpatient stay is the ‘punishment’ for noncompliance.)

The third leg of the proposed reform involved “opening a spigot” of funding for inpatient services that was initially closed to keep states from shifting inpatient costs onto the federal government (the IMD exclusion). “That danger still exists.” Any expansion of residential alternatives should involve a systematic appraisal of the system of care available in each community and a plan for allocation of resources to ensure the range of needed services. “Preferentially funding one component of the system while neglecting others isn’t a smart approach.”

I found an additional problem with the call made by Satel and Torrey for expanding the number of psychiatric beds. They curiously lumped schizophrenia and bipolar in with diabetes to then give a cost figure of $839 million in hospital costs for causes of 30-day Medicaid inpatient re-admissions for adults between the ages of 18 and 64. I thought it was strange to have schizophrenia and bipolar disorder lumped in with diabetes in assessing hospital re-admission costs. Following the above link they provided to the H-CUP data they referenced, it seemed they took their cost figure from Table 3, which contained ten conditions with the most all-cause, 30-day re-admissions for Medicaid patients (aged 18-64).

The first thing I saw was that diabetes costs could have been easily left out of their figure, meaning that $839 million should have been $588 million for schizophrenia and bipolar re-admissions alone. The second thing I noticed was Satal and Torrey referred to the H-CUP category of “Mood disorders” as “bipolar.” Bipolar disorders are mood disorders, but so are the depressive disorders.  The NIH estimate of the prevalence of severe bipolar disorder among U.S. adults was 2.2%. The estimated prevalence for major depression among U.S. adults was 6.7%. If the combined re-admission costs for all mood disorders was $588 million, what was the cost for just bipolar disorders? If the ratio was evenly distributed, it would be roughly one-third of the $588 million figure—$196 million. Or do Satel and Torrey support “assisted outpatient treatment” for individuals refusing to remain on medication for major depression as well as bipolar disorder? What about the less serious mood disorders, like anxiety?

Was the reference of the H-CUP category of “mood disorders” as “bipolar disorder” intentional or not? Traditionally, bipolar disorder is seen as the most serious mood disorder. I don’t believe they were confusing the difference between serious mental illnesses and less disabling psychiatric conditions, as they suggested of the critics of H.R. 2646 and lawmakers above. So unless it was an unintentional slip, they were intentionally referring to the general category of mood disorders by its most serious condition: bipolar disorder.

The underlying assumption for the need of an assisted outpatient treatment (AOT) provision is that the targeted individuals fall into this pattern of self-neglect, self-harm, or dangerousness” because they are not taking medication. But the treatment efficacy for psychiatric medications has been increasingly questioned. Antidepressants have been shown to be of minimal value (See “Dirty Little Secret” and “Do No Harm with Antidepressants” and The Emperor’s New Drugs, by Irving Kirsch for more information). And the adverse consequences from neuroleptics and mood stabilizers have raised serious questions about the long-term use of such medications for schizophrenia and bipolar disorder (See “Creating Chemical Imbalances,” “Antipsychotic Big Bang,”  “Abilify in Denial” and Anatomy of an Epidemic, by Robert Whitaker for more information).

There is nothing benign about the assisted outpatient treatment provision within the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646). But it certainly is coercion. See “Murphy’s Law” for more on H.R. 3717, the original bill. See “Regarding Representative Tim Murphy’s Helping Families in Mental Health Crisis Act” for more information on H.R. 2646.